health

insurance
Pre-authorisation Form

SECTION A (To Be Filled By The Insured/Patient)

A. Name:
B. Gender: Male C. Date of Birth: DD/MM/YYYY

D. Contact No.: E. Contact No. (Attending Relative):

F. Your Id No.: G. Policy No.:
H. Do you hold any other Mediclaim/Health Insurance: Yes No
i) If yes, Corporate Policy No.:
ii) Employee Id:
iii) Give Details:
I. Do you have a Family Physician: Yes No
i) If Yes, Name:
ii) Contact No.:

SECTION B (To Be Filled By The Treating Doctor/Hospital)

DETAILS OF TREATMENT
A. Doctor Name: B. Contact No.:
C. Nature of Illness:

D. Relevant Clinical Findings:

E. Duration of Present Ailment (In Days):

i) First Consultation Date: DD/MM/YYYY

ii) ICD 10 Code:

iii) Past Medical History (If Any):
F. Provisional Diagnosis:

G. Proposed Line for Treatment: Non Allopathic Management

H. If Investigative and/or Medical (Provide Details):
 i) Route of Drug Administration:

I. If Surgical, Name of Surgery:

i) ICD 10 PCS Code:
J. Other Treatments (Provide Details):
L. In Case of An Accident:
i) RTA: Yes No
ii) Date of Injury: DD/MM/YYYY

iii) Reported to Police: Yes No

iv) FIR No.:
v) Injury/Disease caused due to Substance Abuse/Alcohol Consumption: Yes No
vi) Any Test Conducted: Yes No (if yes, attach reports)
vii) Details of Injury:

M. In Case of Maternity: G P L A i) Date of Delivery: DD/MM/YYYY

DETAILS OF PATIENT ADMITTED

Date of Admission: DD/MM/YYYY Time: HH:MM:SS Type of Hospitalisation: Emergency
Expected stay in Hospital (In Days): Room Type:

EXPECTED COST OF HOSPITALISATION Amount in `

Room Rent (Per Day) + Nursing and Service charges + Diet of Patient
Expected Cost for Investigation and Diagnostic
ICU Charges
OT Charges
Professional Fees of Surgeon + Anesthetist Fees
Consultation Charges
Medicines + Consumables + Cost of Implants
Please Specify, if any other Expense
All Inclusive Package Charges (If Applicable)
Total 0.00
PAST HISTORY OF ANY CHRONIC ILLNESS (If yes, please mention since when in DD/MM/YYYY format)
Diabetes: DD/MM/YYYY

Heart Disease/IHD/CAD/Any Other: DD/MM/YYYY

Hypertension: DD/MM/YYYY

Osteoarthritis: DD/MM/YYYY

Asthma/ COPD/ Bronchitis/ Tuberculosis: DD/MM/YYYY

Cancer: DD/MM/YYYY

Alcohol/Drug Abuse: DD/MM/YYYY

HIV/STD/Related Ailments: DD/MM/YYYY

Hyperlipidemia: DD/MM/YYYY

Any other Illness (Give Details): DD/MM/YYYY

SECTION C Declaration (Please Read The Conditions Carefully)

DECLARATION BY THE PATIENT/REPRESENTATIVE:
1. I agree to allow the hospital to submit all original documents pertaining to
hospitalisation to the insurer after discharge. I agree to sign on the final bill and
discharge summary, before my discharge.
2. Payment to hospital is governed by the terms and conditions of the policy. In case,
the insurer is not able to settle the hospital bill, I undertake to settle the bill as per the
terms and conditions of the policy.
3. All non-medical expenses and expenses not relevant to current hospitalisation
and that amounts over and above the limit authorised by the insurer not governed
by the terms and conditions of the policy will be paid by me.
4. I hereby declare to abide by the terms and conditions of the policy and if at any time
the facts disclosed by me are found to be false or incorrect, I forfeit my claim and
agree to indemnify the insurer.
5. I agree that if I had made any false or misrepresentation of facts, suppression or
concealment with respect to claim, my right to claim for reimbursement of the said
expenses shall be absolutely forfeited.
6. I agree to indemnify the hospital against all expenses incurred on my behalf, which
are not reimbursed by the insurer.

Patient/Representative Name:
Contact No.:
Patient/Representative Signature:
HOSPITAL DECLARATION:
1. We have no objection to any authorised insurance company from officially verifying
documents pertaining to hospitalisation.
2. All valid original documents duly countersigned by the insured/patient as per the
checklist below will be sent to insurance company within 7 days of the patient's
discharge.
3. All non-medical expenses, or expenses not relevant to hospitalisation or illness,
or expenses disallowed in the authorisation letter of the insurance company, or
arising out of incorrect information in the pre-authorisation form will be collected
from the patient. We agree that the insurance company will not be liable to make
the payment in the event of any discrepancy between the facts in this form and
discharge summary or other documents.
4. The patient declaration has been signed by the patient or by the representative in
our presence.
5. We agree to provide clarifications for the queries raised regarding this hospitalisation
and we take the sole responsibility for any delay in offering clarifications.
6. We will abide by the terms and conditions agreed in the MOU.

Name of the Treating Doctor:

Qualification: Registration No. (With State Code):
Hospital Seal: Doctor Signature:

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed discharge summary and bills incurred during hospital.

2. Cash memos from the hospitals/chemists supported by Doctor’s prescription.
3. Receipts and pathological test reports from pathologists, supported by note from the
attending Medical practitioner/Surgeon recommending such pathological tests.
4. Surgeon's certificate stating nature of operation performed and Surgeon's bill and receipt.
5. Certificates from the attending Medical practitioner/Surgeon that the patient is fully cured.